When Facts Are Scarce, ER Doctor Turns Detective To Decide On Care

It's just past midnight on a freezing Saturday night in Washington, D.C.

In the last hour, five ambulances have arrived at the emergency room where I work. A sixth pulls up.

The paramedics wheel out a stretcher carrying a man, 73, strapped to a hard board, a precaution in case his spine is fractured. There's blood around his neck brace and a strong smell of urine.

"We found him by his bed," a paramedic tells me. The patient told the paramedics he slipped. "Reports back pain and some cuts and bruises," one of them adds.

Medical history? None the paramedics could find. Same goes for whatever medications the patient might be taking. The only thing they know is his name and address. Nobody else was at home.

Two nurses undress the patient to rid him of his soiled clothes. They wrap a blood pressure cuff around one arm and start an IV line in the other. A tech shaves his chest before attaching sticky electrodes to check the man's heart.

He swats at us, saying that none of this is necessary. He slipped in the shower. "I was only out for a little while," he says. The paramedics mumble that they found him in the bedroom — not the bathroom.

The patient tells us his full name and says that the year is 1843. "It's 2014," I say, as my medical student looks for his records on a nearby computer.

She shakes her head. He's never been in our hospital. He gives us two phone numbers for his son, but neither works. The patient says his doctor lives in Kansas.

We examine him and find a 1-inch laceration over his eyebrow, a bruise over his right wrist, and scrapes on both knees. He winces when I touch his back. He has good strength in his arms and legs.

I send him for X-rays and a CT scan of his head and spine. There's no bleeding inside his brain and nothing is broken. His laboratory tests come back and show that he has anemia and kidney trouble.

He wants to go home. He pleads with us, saying he hates hospitals. He promises he'll be OK. I try his home phone and his son's numbers again. The resident calls two local hospitals on the chance they've seen him before. No luck.

The year is now 1914, the patient declares. Everyone sighs. We have to admit him. It's the last hospital bed we've got, and the patients who come after him will have to wait through the night in the ER.

The next day, I get a call from the patient's son and daughter-in-law. They're irate. The patient has dementia and frequently falls. That's why the family has arranged for live-in help 18 hours a day.

The man has had anemia and kidney problems for years. His longtime doctor (here in town, not in Kansas) monitors these issues closely. The internist taking care of him say that the man never should have been hospitalized.

My first reaction is defensiveness. Where was his family last night? What would the man's usual doctor have done in my position?

We emergency physicians frequently hear complaints from other doctors about how we order too many tests and admit too many patients. While medical overuse is a problem — and fear of malpractice and financial conflicts of interest sometimes play a role — it's easy to make harsh judgments after the fact.

When caring for patients we don't know and who could have life-threatening illnesses, emergency physicians have to do what is safest and best with the information at hand, sparse as it may be.

In this case, I made the choice to admit the patient. He was confused and had several abnormal test results. We couldn't be sure he'd be safe at home.

As I listen to his family, I also see the other side. I can see how unhappy they are that he was stripped, poked and kept against his wishes. I understand their frustration at our system of sick care: Why don't we have unified electronic medical records? Why aren't there better interventions for coordinating care and keeping people out of hospitals?

I tell them that I'm sorry. Knowing what I know now, I would have made a different decision. I gently suggest that it would be helpful to make sure he carries a document in his wallet with updated phone numbers, medical conditions and wishes for his care.

That day, I'm back in the ER. It's another busy shift, and I see him again. Well, not the same 73-year-old, but another elderly gentleman who also fell. Again, he's confused, and we can't reach his family. He doesn't want to stay, but again we hospitalize him. This time, too, I'm filled with doubt and a desire for a better system to care for my patients.